DENTAL STUDIO BRUNSWICK STREET | Family-focused Dental Care in Stratford, ON

NEW PATIENTS

Thank you for choosing us as your dental provider of choice. We are accepting new patients, however, please be advised that the appointment times for new patients may exceed 3 months. For immediate new patient appointments, reach out to our sister clinic, Dental Studio Front Street and they would be happy to take you on! Book online with Dental Studio Front Street or call them directly.

Or, you may fill out the request form below and will do our best to accommodate you.

Request An Appointment

Use form below if you’d like to book an appointment. We will contact you to confirm a suitable appointment time.

Name(Required)

First Last

Phone(Required)

Additional Comments

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Medical History Questionnaire

Your information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone (Home)(Required)

Phone (Business)

Address (Home)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address (Business)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Who referred you to our office?

In case of emergency, we should notify:

Name(Required)

First

Relationship(Required)

Day-time Phone(Required)

Name of family doctor

Phone or address

Name of medical specialist

Area of specialty

Phone or address

Name of medical specialist

Area of specialty

Phone or address

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?(Required)

Yes

Not sure, maybe

Please specify(Required)

2. When was your last medical checkup?(Required)

3. Has there been any change in your general health in the past year? If yes, please explain.(Required)

Yes

Not sure, maybe

Please specify(Required)

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list.(Required)

Yes

Not sure, maybe

Please specify(Required)

5. Do you have any allergies? If you answered yes, please list using the categories below:(Required)

Yes

Not sure, maybe

a) medications b) latex/rubber products c) other (e.g. hayfever, foods)

Please specify(Required)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.(Required)

Yes

Not sure, maybe

Please specify(Required)

7. Do you have or have you ever had asthma?(Required)

Yes

Not sure, maybe

8. Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

Not sure, maybe

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?(Required)

Yes

Not sure, maybe

10. Do you have a prosthetic or artificial joint?(Required)

Yes

Not sure, maybe

11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?(Required)

Yes

Not sure, maybe

12. Have you ever had hepatitis, jaundice or liver disease?(Required)

Yes

Not sure, maybe

13. Do you have a bleeding problem or bleeding disorder?(Required)

Yes

Not sure, maybe

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain(Required)

Yes

Not sure, maybe

Please specify(Required)

15. Do you have or have you ever had any of the following? Please check.(Required)

chest pain, angina

heart attack

stroke

shortness of breath

rheumatic fever

mitral valve prolapse

heart murmur

pacemaker

lung disease

tuberculosis

cancer

steroid therapy

diabetes

stomach ulcers

arthritis

seizures (epilepsy)

kidney disease

thyroid disease

drug/alcohol dependency

osteoporosis medications (e.g. Fosamax, Actonel)

16. Are there any conditions or diseases not listed above that you have or have had? If so, what?(Required)

Yes

Not sure, maybe

Please specify(Required)

17. Are there any diseases or medical problems that run in your family?(Required)

Yes

Not sure, maybe

(e.g. diabetes, cancer or heart disease)

Please specify(Required)

18. Do you smoke or chew tobacco products?(Required)

Yes

Not sure, maybe

19. Are you nervous during dental treatment?(Required)

Yes

Not sure, maybe

20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?(Required)

Yes

Not sure, maybe

Please specify your expected delivery date(Required)

DENTAL STUDIO BRUNSWICK STREET

Forms & Documents

We invite you to download, print and complete the necessary documents at home to make your visit with us as efficient as possible.

Medical History Questionnaire
Records Release Form
Financial Agreement
Patient Consent Form

DENTAL STUDIO BRUNSWICK STREET | Family-focused Dental Care in Stratford, ON

NEW PATIENTS

Request An Appointment

Medical History Questionnaire

DENTAL STUDIO BRUNSWICK STREET

Forms & Documents

Questions?

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